Surgical Oncology

Surgery plays a central role in the management of most cancers. In most instances, it is still the only treatment that reliably offers the patient the possibility of a cure. However, in order to achieve the best possible results, all cancers should be treated by a multi-disciplinary team consisting of an experienced surgeon, a radiologist and an oncologist. The following principles are broadly applicable to most cancers.

1. Screening:

Most cancers grow relatively slowly and may take many months or more likely years to grow large enough to become symptomatic. Presenting symptoms may thus be very subtle and insidious in onset. In order to diagnose cancer early and ensure the best outcome, the GP or surgeon needs to have a high index of suspicion, or the patient needs to take part in regular cancer screening tests. There are different types of cancer screenings such as Pap smear for cervical cancer, clinical breast examination and mammography for breast cancer, antigen blood tests for prostate cancer and photographic mole-mapping for skin cancer. Cancer screening guidelines for colorectal and breast cancer are well established, but unfortunately not practiced widely.

2. Diagnosis:

The consequences of a cancer diagnosis can be dire (the emotional burden, the need for major and sometimes disfiguring surgery and treatment with potentially toxic chemotherapy agents). Therefore we need to establish the diagnosis beyond doubt. The best way to do this is to obtain tumour cells (fine needle aspiration) or better still tumour tissue (large core needle biopsy or incisional biopsy). Dr Cooper may request a pathological examination of these specimens to either confirm or exclude the presence of cancer. In some cases, a blood test (called a tumour marker) may exist that is very specific for that cancer, i.e. primary liver cancer. In such cases, a positive test for the tumour marker might be sufficient to establish the diagnosis. In rare instances, cancer may be in such an inaccessible spot such as a tumour in the head of the pancreas that it may be impossible to obtain a reliable tissue diagnosis. In these cases, the diagnosis may be presumed and surgery performed based on the patient's symptoms and the imaging characteristics of the tumour.

3. Staging:

Once the diagnosis of cancer has been confirmed, cancer needs to be ‘staged’. This refers to appraising to the local extent (and resectability) of the tumour, the extent of lymphatic (‘glandular’) spread and the presence/absence of distant organ spread (metastases). Dr Cooper may recommend either a CT or MRI scan to be done of the area in question. A PET CT, bone scan or chest CT might be necessary to exclude distant organ (metastatic) spread. Determining the stage of the cancer is extremely important as this directs the order and extent of future surgery and oncological treatment and is also an important predictor of prognosis.

4. Neo-adjuvant treatment

The term ‘neo-adjuvant treatment’ describes the use of chemotherapy and/or radiotherapy before surgery. There are numerous potential advantages to the use of pre-operative radio-/chemotherapy:

• Systemic treatment (chemotherapy) is given as early as possible in the disease process.
• The size of the cancer / tumour can be decreased, and the extent of the resection can potentially be less extreme.
• The patient may physiologically be in a better state to tolerate the chemotherapy before rather than after a major surgical procedure.
• The biology or 'aggressiveness' of cancer can be assessed early on by gauging the response to chemotherapy and will have an impact on future treatment and also on predicted prognosis.
5. Surgery:

Surgery can be done with either curative or palliative intent. If the intention is to cure cancer, the aim of surgery will be to resect all macroscopic tumour and as many lymph nodes that drain the area of the tumour as possible. If the aim is palliation it means that cure is no longer possible, and surgery will be done to treat (palliate) current symptoms or prevent future cancer symptoms/complications. Surgery can be done open or in a minimally invasive manner. The advantages of minimally invasive surgery have been well documented previously.

6. Adjuvant treatment
• Radiotherapy:

Radiotherapy is the use of ionizing radiation to control or kill malignant (cancer) cells. Radiotherapy can be curative in certain forms of cancer if it is localized to a specific area. However, it is mostly used as an adjunct to surgery before (neoadjuvant) or after (adjuvant) the surgical procedure. The aim would then be to either shrink the tumour (before surgery) or to destroy residual microscopic disease (after surgery) and prevent a local recurrence. Radiotherapy is synergistic with chemotherapy and is usually used before, during or after chemotherapy in susceptible cancers. Radiotherapy will be overseen by an oncologist who will discuss the treatment and possible side-effects in much more detail prior to beginning treatment.

• Chemotherapy

Chemotherapy is the treatment of cancer with medication that kills cancer cells (also called cytotoxic or antineoplastic drugs). These drugs act by killing cancer cells that divide quickly (one of the main properties of most cancer cells). Unfortunately, chemotherapy also harms other cells that divide rapidly under normal circumstances: cells in the bone marrow, digestive tract, and hair follicles. This results in the most common side-effects of chemotherapy: myelosuppression (decreased production of red blood cells causing anaemia and also white blood cells causing immunosuppression), mucositis (inflammation of the lining of the digestive tract) and alopecia (hair loss). Chemotherapy can either be administered with the intent to cure cancer (curative) or where cure is not possible; it can be administered to prolong and improve quality of life (palliative intent). Chemotherapy will be administered by an oncologist who will discuss the treatment and possible side-effects in much more detail prior to beginning treatment.

• Immunological therapy:

Immunological therapy, also known as targeted therapy or molecular therapy, refers to types of medication that block the growth of cancer cells by interfering with specific targeted molecules needed for development and growth of cancers, rather than by simply interfering with all rapidly dividing cells (e.g. with traditional chemotherapy). These drugs are at the forefront of cancer treatment research and are expected to be more effective than current treatments such as chemotherapy, surgery or radiotherapy, and less harmful to normal cells (i.e. fewer side-effects).

7. Follow up:

Once you have completed the full course of cancer treatment (surgery, chemotherapy, radiotherapy and/or immunological therapy), you will be required to come for regular follow-up appointments with your surgeon and/or oncologist (even if you are deemed ‘cured’ or free of cancer). Follow-up investigations such as colonoscopies, mammograms, blood tests, ultrasounds or CT scans will also periodically be necessary. The interval of these visits will be determined by the time span that you have been cancer-free.